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LCME Visit Details

 About LCME Standards:

LCME accreditation is a voluntary peer review process of quality assurance that determines whether the programs meet accreditation standards.1 All  M.D. programs in the U.S. and Canada must demonstrate compliance with accreditation standards to maintain their accreditation status. The 12 standards are:

Standard 1: Mission, Planning, Organization and Integrity

Standard 2: Leadership and Administration

Standard 3: Academic and Learning Environment

Standard 4: Faculty Preparation, Productivity, Participation, and Policies

Standard 5: Educational Resources and Infrastructure

Standard 6: Competencies, Curricular Objectives, and Curricular Design

Standard 7: Curricular Content

Standard 8: Curricular Management, Evaluation and Enhancement

Standard 9: Teaching, Supervision, Assessment, and Student and Patient Safety

Standard 10: Medical Student Selection, Assignment, and Progress

Standard 11: Medical Student Academic Support, Career Advising, and Academic Records

Standard 12: Medical Student Health Services, Personal Counseling, and Financial Aid Services

Additional information on the specific requirements for compliance can be found in the document Functions and Structure of a Medical School for site visits in 2016-2017.


 About the LCME Self Study:

To demonstrate compliance with 12 standards, a team of LCME peer reviewers participate in a site visit. The team uses the following sources of information to judge compliance:

  1. Self Study: A report from the program summarizing its self review findings.
  2. Data Collection Instrument: Programs complete tables and answer questions about their compliance with specific requirements related to the 12 standards.
  3. Independent Student Analysis: An independently run student led review of LCME standards using a student survey developed by students.
  4. AAMC Graduate Questionnaire: A review of multi-year graduating survey results elicits any areas where CUSOM has performed less than expected when compared with its medical school peers.
  5. Site Visit: Interviews by the site visit team will also indicate any issues that come up during the site visit.
  6. Additional Supporting Evidence: Any supporting evidence CUSOM provides the site visit team up until its exit interview can be used to demonstrate our program’s compliance with LCME’s standards.

 Timing of Accreditation Efforts for the 20162017 Site Visit

LCME Project Milestones:

  1. Preliminary Data Collection Instrument information collected in August, 2015.
  2. Launch of Independent Student Analysis with Dean and student Co-Chairs on August 18, 2015.
  3. Launch of LCME Committees and Task Force at LCME Kickoff Event on September 2, 2015.
  4. Results of Independent Student Analysis (ISA) shared with Faculty Accreditation Lead Robert Anderson in March, 2016.
  5. LCME Committees finalize reports/DCI materials in July, 2016, incorporate ISA findings in recommendations for improvement. Committees share recommendations for improvement with those responsible for changes.
  6. Task Force synthesizes LCME Committee reports and ISA results into self study summary in October 2016. Task Force shares recommendations for improvement with those responsible for changes.
  7. CUSOM continues to follow up on action plan improvements based on self study review.
  8. CUSOM updates Data Collection Instrument in November 2016.
  9. CUSOM submits completed self study and Data Collection Instrument to LCME in December 2016.
  10. CUSOM has a mock site visit to prepare for LCME site visit in October 2016 or February 2017.
  11. CUSOM welcomes LCME site visit team to campus, March 5-8, 2017. CUSOM follows up on any recommended actions outlined by LCME’s letter of the accreditation decision, after the June 2017 LCME meeting.

 CUSOM’s History of Accreditation

The last site visit occurred in March, 2009. In its accreditation decision, LCME elected to continue an ‘unspecified term of accreditation’, requiring a follow up visit to assess compliance. A follow up visit is considered a ‘severe action decision’ by LCME. The areas of partial or substantial non-compliance were:

  1. Student Debt
  2. Student/Faculty Diversity
  3. Affiliation Agreements with Clinical Affiliates

The following areas in transition required monitoring by LCME:

  1. School Financing
  2. Student Mistreatment
  3. Curriculum Management
  4. Timeliness of Grades for Clerkships

Since the 2009 site visit, CUSOM has had 1 follow up focused visit to address LCME concerns, and 3 status update reports submitted to LCME to demonstrate compliance.

CUSOM’s LCME CQI efforts focus on the above areas as well as additional areas of improvement.


 Independent Student Analysis

A key element for accreditation is an Independent Student Analysis. Students lead efforts to survey the entire student body about LCME standards, and analyze student survey results. A high response rate is essential, and strengths and issues identified by students will be addressed in planning efforts of LCME Committees and the LCME oversight body called the LCME task force. We have asked students to provide their report in March 2016 so that we may follow up and address as many findings as possible in preparation for the 2017 site visit.

The CoChairs of the Independent Student Analysis are Hamza Pasha and Anna Schubert. These student leaders will lead a group of 30 students in the ISA efforts. Thank you to all of our students for their engagement in the process.

Link to ISA packets


 Goals for 20162017 Site Visit

Preparation is Key:

Addressing CUSOM’s compliance issues early is key to having a successful site visit in 20162017. That is why the LCME core team has been working on early data collection in 2015 in advance of the launch of LCME Committees. The earlier CUSOM can identify unknown compliance gaps and address them, the more likely we will have a successful site visit experience. Addressing known vulnerabilities in advance helps us be prepared.

Preparation for 2 New LCME Standards:

As part of CUSOM’s efforts to prepare for changes in LCME standards for site visits in 2016-2017, the SOM prepared to address 2 new LCME requirements for interprofessional collaborative skills (7.9) and continuous quality improvement (1.1). The newly offered IPED course brings multiple health profession students together to hone their team collaboration skills and better understand professional roles in teams. The course also focuses on patient safety and ethical decision making.

To address a new standard on continuous quality improvement (1.1), a new position was created, the LCME Accreditation Specialist, who monitors changes in LCME standards and follows up with actions to address them on a continuous basis. In addition, a holistic review of compliance vulnerabilities led to early data collection. Data collection helps identify compliance gaps and improvement plans before the start of the LCME Committees in September, 2015.

Robert Anderson, MD, the Faculty Accreditation Lead, has worked closely with units to address areas of compliance risk, in advance of the self study review.

LCME Notifications (5.12):

CUSOM is expected to notify LCME of all substantial changes impacting resources in the medical program curriculum. As such, in 2013, CUSOM notified LCME of its intention to increase the class size to 184 from 160, and have 24 students located at a new branch campus in Colorado Springs during Phase III. Students begin Phase III in April 2016.

CUSOM also notified LCME of its intention to offer a Longitudinal Integrated Curriculum in July 2015. LCME will review the branch campus during its March 2017 site visit.


If you have any suggestions on how to improve CUSOM’s preparation for LCME accreditation, please do not hesitate to go to the Contact page and contact a member of the LCME team.